Out of the 15 patients enrolled (13 men, 2 women), six did not complete the study intervention. The reasons for non-completion included discharge without equipment (n=1), withdrawal of consent (n=2), post-surgical complications leading to extended hospital stay (n=2), and one patient's unfortunate passing. In total, nine participants successfully engaged in both the intervention and subsequent interviews. All participants' characteristics are detailed in Table 1. Five patients had joint interviews with a relative, while the other four were interviewed alone. These sessions took place between September 2022 and March 2023, averaging 34 minutes each (range: 25–43 minutes.
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We conducted interviews with two female physiotherapists, one of whom held a master's degree. They possessed 19 and seven years of work experience, with over 10 and 3.5 years of specialization in CR respectively. These interviews with the physiotherapists took place in March 2023, each lasting 65 minutes.
Interview findings
Data were analysed and categorized into three themes: 1) creating an individual fit by tailoring the intervention; 2) prioritizing communication and collaboration; and 3) interacting with the mHealth application. Themes and sub-themes are presented in Table 2, with more illustrative quotes available in Additional file 2.
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Theme 1: Creating an individual fit by tailoring the intervention
1a: Unilateral focus on exercise and physical factors
Perceived from the patients' standpoint, the intervention primarily emphasized physical activity and exercise, enhancing their awareness of and ability to engage in regular physical activity, pushing them to go beyond everyday tasks. Tracking exercise completed and distances walked allowed them to monitor progress and goal attainment. However, some patients and relatives criticized the intervention for neglecting well-being and psychosocial aspects. They requested the physiotherapists to address emotional and motivational aspects like mood, energy, and insecurity.
“It is a limitation [that the intervention did] not [address] the psychological issues, which relatives ought to know about.” R4
The physiotherapists emphasized the importance of addressing the patients' physical activity level and acknowledged that time and opportunities to discuss patients’ experiences and concerns were limited.
1b: Acknowledging a demanding start
Delays in starting exercise were mainly due to prolonged hospital stays because of post-operative complications. Starting the programme after discharge required strong self-discipline. Reduced strength, dizziness, pain, and breathlessness exacerbated the situation, making physical activity more challenging. Fatigue and depression were major barriers to start-up, and the exercise programme's workload added to the burden.
“I don’t think the programme did any good. When I took it home, my body said no, and it was a kind of defeat that I could not do these exercises in the programme, and it caused some frustration.” P6
Additionally, mental and emotional elements such as anxiety, resignation, lowered mood, anger, irritability, and scepticism were mentioned as influencing patients’ physical activity efforts – but also their engagement in supportive social relationships.
The physiotherapists acknowledged the demands of initiating exercise but found it difficult to help the patients overcome barriers related to physical and mental difficulties within the current intervention design. They realized that delivering and supporting the mHealth intervention required additional physiotherapist resources compared to usual treatment.
1c: Individual adaptions responding to users’ preferences and capacities
Some patients tried to adapt the programme to their needs, altering repetitions or dividing exercises into multiple sessions. Others waited for the physiotherapists to make adjustments, which were generally welcomed despite not always being a perfect fit. However, the intervention did not entirely match the diverse preferences, needs, skills, and capacities of all the patients and relatives. A more tailored approach can be expected to heighten its effectiveness.
“I did 60 [repetitions], then 30 and then the other leg…that’s how I increased [the number of exercises]. I have done more than 326 [repetitions]…but that was because it was the only exercise I could really do.” P9
Patients' prior experiences and activity preferences varied, leading to diverse responses to the intervention. Some felt empowered by the programme, overcoming barriers and taking responsibility for their physical activity. Some managed to improve the programme fit by altering repetitions or dividing exercises into multiple sessions, enjoyed exercising enthusiastically, and were pleasantly surprised by their improved well-being and mood. Conversely, some experienced physical discomfort and discouragement and felt disheartened when they were unable to keep up with the programme. Some of them attempted to seek support from the physiotherapist to match the workload to their capacities, while others refrained from seeking support. The majority of the patients preferred doing routine tasks like housekeeping, gardening, walking or cycling.
The physiotherapists reflected on better integration and prioritization of everyday tasks. They perceived it as challenging to make individual adaptions primarily based on sensor feedback with only limited knowledge about patients’ preferences and capacities. The patients, relatives, and physiotherapists all emphasized the importance of having an alternative to mHealth for vulnerable patients who require a more comprehensive rehabilitation plan.
Theme 2: Prioritizing communication and collaboration
2a: Sufficient support and follow-up
The text messages from the physiotherapists with reminders and encouraging comments were well received by the patients. They viewed these as expressions of interest and engagement, providing security and motivation.
“Somehow, I felt that someone was on the other end saying, ‘It looks fine, what you are doing,’ registering and following what I did. That was nice.” P4
Despite being explicitly informed of it before discharge, participants rarely utilized the option to reach out to the physiotherapists via text message or phone call. Contact criteria remained unclear, as the physiotherapists expected two-way communication while patients often preferred to manage their activity independently. To address this missed communication with some patients, we added one or more phone calls to provide follow-up to those who refrained from seeking support. The subsequent dialogues emphasized the vital necessity for personalized contact, covering well-being, programme execution, and daily concerns. The physiotherapists emphasized the importance of allocating ample time to addressing individual needs and concerns to ensure effective implementation and intervention quality.
2b: Balancing obligations and responsibilities
Among those capable of engaging in the exercises and tasks, the intervention was perceived as motivating and added to their sense of responsibility. Others regarded it as an unwanted duty and felt burdened by high expectations for rigorous physical activity, leading to discouragement. Having consented to test the mHealth app intervention made them feel obligated to complete the programme. The exercise programme was not always well matched to patients' abilities or preferences.
“I could only manage a few repetitions of the exercise before feeling exhausted, and then the counter indicated that I had to complete another 30 repetitions.” P14
Being unable to complete the programme added to a sense of defeat and made some give up and stop using the technology. Sharing responsibility with others eased the burden.
The challenge for the physiotherapists was to facilitate physical activity without making patients who were incapable of completing the full exercise programme feel inadequate or guilty.
2c: Involvement and roles of relatives
All the relatives wanted increased involvement, for example by being present for the decision about enrolment, the introduction of the technology, and the presentation of the exercise programme. They were viewed as a resource by the patients. However, they lacked knowledge about how to support initiation of the exercise programme and adherence to it when difficulties or complications arose. It was challenging for the relatives to balance their behaviour between pressure and support without impacting on their relationship with their loved ones in a negative way. Disagreement between patients and relatives about physical activity efforts could result in conflicts and frustrations for both.
“I am sure I could easily have completed it [the programme] without having a physiotherapist as back-up.” (P12) (The relative adds:) “I don’t think you would have been able to, if the physiotherapist had not been there during the first weeks.” R12
The role of an engaged relative could be demanding. Some sought more information, guidance, and professional support, while others engaged their network for assistance with the technology, adapting the programme or deciding to discontinue exercise.
The physiotherapists perceived the relatives as an important resource for the patients but did not involve them systematically.
Theme 3: Interacting with the mobile health application
3a: Using technology and monitoring
Operating the smartphone, app, and text messages proved to be straightforward for the majority of patients. Even those who were initially worried by the technology were pleasantly surprised by their proficiency, with only a few needing assistance initially. Patients particularly appreciated the visual exercise guides, the monitoring features, and the reassurance provided by the option to communicate with their physiotherapist.
Some patients found monitoring their exercise gave them enjoyment, prevented boredom, and provided a sense of security, encouragement, and collaboration. Competitive patients used the monitoring to compete with themselves by following their progressions and reaching their explicit goals. Others perceived the monitoring of exercises as a way of having their exercise efforts measured and controlled as well as having their incompetence exposed. Two participants mistakenly took the sensor to be for online surveillance of physiological parameters, e.g. blood pressure during activity.
Initially, the physiotherapists did not consider the elderly to be a suitable target group for an mHealth app intervention and anticipated potential barriers to adoption.
“In the group of elderly we want to reach, there may be some who feel like strangers to technology and have difficulty in using it on their own. If they [the patients] can make it [the technology] work, I think it would be very good for some of them.” PT
The physiotherapists viewed the monitoring as an exercise diary that illustrated programme suitability and demonstrated the patients' self-management abilities. However, they acknowledged the risk of overlooking concerns and challenges for the patients that were not captured in the data.
One patient found the technology troublesome and discontinued using it. Another quit the programme because it was too burdensome.
3b: Timely delivery and organization of intervention
Identifying the ideal time frame for equipment delivery and instruction before discharge presented practical challenges and was difficult to coordinate with treatment and care activities for the patient. In some cases, last-minute discharges prevented relatives from being invited to or attending the session giving instructions. Receiving, understanding, and remembering information and making decisions about enrolment were difficult for some patients close to the time of surgery.
“I did not pay much attention to the instructions because the surgery filled me up. Actually, it was in my head for the last three weeks…because I was pretty sure that I would succumb, and I guess I thought, ‘Well, just let me get it over with.’ I probably didn’t listen as I should have done.” P15
The amount of information was perceived as being overwhelming and caused a sense of information overload in some of the patients. The time allocated for the instructions and repetitions was insufficient from the perspective of the physiotherapists and did not meet the needs of participants with reduced short-term memory or attention problems. One physiotherapist found the organization and procedures suboptimal and wondered if a specialized university hospital was the right setting for delivering the intervention.
3c: The value of closing an intervention gap
The aim of becoming active early after surgery was consistent with the values of the patients, the relatives, and the physiotherapists. The intervention was considered to be effective, meaningful, encouraging, and motivating and made a positive difference for most patient and relatives.
“The exercise would not have been systematic if it had not been for the programme. It would have been random. A programme like this commits me to others. I think that is the value of it.” P4
The flexibility was appreciated, as it made the exercise easy to fit into everyday life, and the fact that no transport was required reduced the risk of patients feeling they were being a nuisance to others. Some patients considered the intervention to be a helping hand to get started, whereas others only participated because it was a research project. The intervention inspired some to continue exercising and attend the centre-based CR in the municipality. Others were more reluctant and wanted to talk to the rehabilitation team before deciding to enrol. Despite their different experiences of the intervention, all participants and their relatives would recommend the intervention to others.
The physiotherapists considered the intervention to be relevant to prevent fatigue, inactivity, and loss of muscle in elderly patients. They were not convinced that the mHealth app was suitable for all patients or better than their usual guidance to patients on being physical activity after surgery. However, they could see the potential of the mHealth app as a complementary method to supplement existing CR.
In summary, various facilitators and barriers are relevant to consider in the delivery of the intervention (see Additional file 3).